Tuesday, January 31, 2006

First Do No Harm

The old saw in medicine: first do no harm. It could be profitably extended to the repairs of the health care system, but few politicians care about the actual delivery of health care. It's mostly politics rather than policy for them. After all, they can afford any type of treatment or provider they desire.

It makes me sick to think about it. How is that for a joke? More seriously, the new proposals for fixing the system that Bush has come up with are not going to fix the system. What they are going to do is to create more desperation and more premature deaths, and they are unlikely to save much in money. Some, sure, because some people will stop seeing physicians and so save us the costs of trying to keep them healthy or even alive. Perhaps a little bit too cynical, but you see the point.

Or you will see the point after I tell what the problems of the health care system fixing are. Consider this: Every health care system has three goals:

1. To provide fair access to all in need.

2. To provide fair quality of care.

3. And to do all this at the least possible cost.

If you think about it a little you can see that the third goal fights the first two. It would be easy to guarantee that every single person in this country gets very high quality care, if we were willing to spend all the resources we have on it. Except in that case there would be no money or time left for anything else.

Add to this the complications that arise because patients really can't judge quality very well and can't do comparison-shopping in, say, appendectomies. Then add the fact that we have over forty million uninsured people who are either going to have no care or care paid by the rest of us, and you can see the political stew boiling. There will be accusations of free-loading by the indigent, there will be accusations of the first accusers wanting to see the uninsured die on the street in front of the accusers house and so on.

What Bush is focusing on in his proposal is really the third goal of the system, and he is grasping market straws as his solution. The idea is to make people responsible for their own health care costs via Health Savings Accounts (HSAs). They work like the world without any health insurance: you save and save for future illness, except you get a tax deduction on the money and some clerk in some office will decide which expenses will be covered out of that account.

Then you are supposed to go to the hospital department store and to walk around with a basket over your arm and to pick up operations and physicians and nurses and turn them over and see what the price tags are, all the time muttering to yourself: "I might need a pneumonia cure some day." By being responsible for spending your own money you will shop carefully and we will all save money! Too bad that the way we buy medical care doesn't fit this model at all. Even worse, the easiest way to get the price of medical care down is by skimping on the quality and usually few people will notice. And even worse than that: unconscious people don't shop around, people in great pain don't compare prices.

The Bush plan will not work. It won't hurt the wealthier among us, because they have plenty of private coverage for whatever they might need and even plenty of ordinary savings to use. But it will hurt the rest, the majority, by making health care less available and less affordable and by inflicting the patient with a burden of careful shopping that just is not possible in many medical need cases.

There are plans that would work better. We could focus on cost-containment on the side of the providers: equipment manufacturers, hospitals and drug firms, to begin with. We could undo the tiny provision slipped into the Medicare bill which bans the government from using its gigantic bargaining power to get better prices on the medications the elderly use. We could do a lot of stuff like that, but it would hurt Bush's base: the haves and the have-mores.